SERVICE REQUEST
Customer Name (First Last):
Customer Phone (Digits Only):
Sales Order Number:
Customer Email:
Communication Preference:
Phone
Email
Address:
City:
State:
Select
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AK
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Zip:
Product Description:
Model:
Manufacturer:
Purchase Date:
Serial:
Retailer:
Unit Failure Description:
Accidental Damage Claim:
No
Yes
Who was using the item?
Where did the incident occur?
When did the accident occur?
How did the accident occur?
What is damaged?
Furniture Claim:
No
Yes
Date Failure was Identified:
Attach Invoice and/or Images:
Person Submitting Request:
Person Submitting Request Phone:
Person Submitting Request Email:
Has anyone in the home been diagnosed or tested due to symptoms for COVID-19 in the last 14 days?
Select
No
Yes
Has anyone in the home has any combination of symptoms consistent with COVID-19 in the last 7 days?
Select
No
Yes
Has anyone in the home come in close contact (within 6 feet) with someone who has been diagnosed
with or waiting test results for COVID-19 due to symptoms within 14 days?
Select
No
Yes
I accept the
terms of service
I have completed all manufacturer suggested troubleshooting. I acknowledge that if it is determined that the service provided on my product is not covered under the Terms & conditions of my service plan, I will be responsible to pay the service provider for the service call. I may also be responsible for mileage charges outside of a certain radius per my Terms and Conditions.
Close
Date of Request:
2021-May-06
Verification Code:
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Type the text:
Be as specific as possible
Explain what is not functioning properly. Be as specific as possible.
Please attach images if this is a furniture claim.
Please attach images if this is an Accidental Damage from Handling claim.
